NANDA has got me brain dead!!

hi, nurse_kadz, and welcome to allnurses! :welcome:

your problem is not nanda as much as it is the nursing process itself. you can't do anything about identifying any patient problems here until you roll up your sleeves and get yourself involved in the problem solving method. that's what we nurses do; that's what you are supposed to be learning from exercises like this; it's what you will be doing on the job as an rn until the day you retire or quit; and actually, you've been following a form of the nursing process most of your life anyway but just didn't call it the nursing process or logically think about what you were doing.

the nursing process is a problem solving method. it is useful for helping you with all kinds of puzzles. you will often find yourself in the role of a detective as a nurse. and a detective does two things: collect evidence (data) and try to put the evidence together to tell a story (solve the problem). if you learn anything, learn the five steps of the nursing process and what goes on in each step. be able to rattle this off in your sleep. it will help you pick correct answers on tests:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
2. determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
   
3. planning (write measurable goals/outcomes and nursing interventions)
   
4. implementation (initiate the care plan)
   
5. evaluation (determine if goals/outcomes have been met)

and when i say that you have been using this process all your life to solve problem, here is an analogy to illustrate what i meant:

so, if you think back on how you fix problems that arise in your life you will realize that you do indeed go through these five steps one way or another. nursing school is just laying them out for you on paper and giving each step a name and some very specific activity to do during each of the steps. regardless, it is important that you follow the steps of the process in the sequence that they occur as if you were following a recipe. one of the biggest errors i see in problem solving is that students read a scenario or start work on a care plan and go right for the second part of step #2, the nursing diagnoses. if you don't put in the preliminary work to get to them, then, of course, you're going to hit the proverbial brick wall! that's the price we pay for not thinking rationally, or critically like good little scientists and detectives!

lets look at the scenario, apply the rhetoric and see if we can save your sanity.

step #1 (assessment) - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology

• medical diagnosis: schizophrenia
  
• mental health patient
  
• 28 years old
  
• male
  
• lives alone
  
• several admissions due to cannabis use
  
• has been non-compliant with treatment
  
• difficulty getting up in the morning, getting to college, and getting in to see his mental health caseworker
  
• keen and interested in learning about the impact of cannabis use in schizophrenics

for scenarios of make-believe patients like this it is almost impossible to do physical and adl assessments, so you pretty much have to skip them, or if you discover specific physical or adl deficiencies that are mentioned in your reading about the disease, i would add them to the list of data that you are collecting because anything goes here and the point of doing these kind of case studies is to learn about these disease processes and how patients respond to them. the other thing you need to do here is look up information about schizophrenia (not one of my favorite diseases because it is complicated and there is a lot to know about it). you need to find out its pathophysiology (and you're going to find there are differing opinions on this) which you need to know in order to classify and structure some of your nursing diagnostic statements later on in step #2 of the nursing process. most importantly, you need to know what the signs and symptoms of this disease are. the scenario didn't list very many. any nursing diagnosis that you will later apply (in step #2) to a patient must be supported by signs and symptoms. (in other words, detective, you need evidence, or proof, in the form of actual subjective/objective data.) you should also see what treatments (medications, tests, etc.) the doctors normally order because guess who gets to carry out many of them, or at see to it that they get done? so future rn, its your responsibility to know whether the doc is ordering appropriately, leaving orders out, or ordering off the wall stuff.

some of the symptoms of schizophrenia (this is not inclusive because i do not have real good mental health references here at home (my background is med/surg):

• decreased emotional expression
  
• impaired concentration
  
• delusions
  
• hallucinations
  
• disorganized speech
  
• grossly disorganized or catatonic behavior
  
• flat affect or inability to make decisions or speak
  
• [and this is interesting!] one or more major areas of functioning (work, relationships, self-care) are markedly below previous level, and the disturbance isn't due to a substance, medical condition, or schizoaffective or mood disorder [i think this gives you a different view of this patient's interest/use of cannabis in relation to his symptoms. to my way of thinking he's got a substance abuse problem while the scenario seems to be trying to entice you to think the cannabis use might be contributing to his schizophrenia--don't think that's the case.]
  
• (page 714, nurse's 5-minute clinical consult: diseases)

if you do not have any disease references at home there is always the library, or you can find information on some of the web sites listed on this thread:

• https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites

you can never have too much data. the mistake most students make is not having enough data. you never know where an important clue is going to be lurking in the data. also, as a student, it is extremely important that you read and learn about the various medical diseases. while we are not doctors, we do need to be very much aware of what doctors are diagnosing, ordering for patients, and why they are ordering things for patients. to help students understand this i developed a critical thinking flow sheet for nursing students some time ago. the link for it is attached at the end of all my posts. all you need to do is click on it to open the file. once opened, you can either download or copy it. it will help you organize and study medical diseases and conditions. in general, doctors order treatments and tests to target the symptoms the patient has. occasionally, they aim at the underlying cause of a disease in an attempt to cure (as in giving antibiotics to treat infections).

step #2 (determination of the patient's problem(s)/nursing diagnosis) - (1)make a list of the abnormal assessment data, (2) match your abnormal assessment data to likely nursing diagnoses, and (3) decide on the nursing diagnoses to use

first, make a list of abnormal data, or signs and symptoms that the patient has. for a make-believe patient like this you may want to include symptoms from your reading of schizophrenia or more clearly define the symptoms the scenario has given you based on what you find in your reading. i suggest you check with your instructor to make sure he/she is ok with this because your grade is at stake here.

ok, nanda. the north american nursing diagnosis association. they publish the nursing diagnosis taxonomy. do you know what this is? learning what it is and how to use it is about to make your life determining nursing diagnosis a whole lot easier. there are currently 188 nursing diagnoses for which nanda has developed

• a definition (actually, this is a more descriptive statement of the nursing problem)
  
• defining characteristics (actually, these are merely the signs and symptoms that support the problem)
  
• related factors (the etiology, or underlying cause, of the problem) - often you need to understand the pathophysiology of the disease process going on to choose the correct related factor connected with a physiological nursing diagnosis
  
• risk factors - these are etiologies that are only listed with the anticipated, or potential, (have yet to occur) nursing problems. these are the nursing diagnoses that begin with the words "risk for" and are used when the patient is vulnerable to possibly developing a problem.

what you need to do is get a copy of it. where is the taxonomy? it has to be purchased from nanda. many authors of care plan and nursing diagnosis books have already done this for you. they usually print this information right below the title of a nursing diagnosis. it doesn't take up much space. in their publication, nanda-i nursing diagnoses: definitions & classification 2007-2008, most of the taxonomy information only takes up one page, two at the most. that is the reference i use the most because it is compact and only about 340 pages with just the information listed above. you can only purchase this from nanda. there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:

• http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
  
• http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm

as i said earlier: any nursing diagnosis that you apply to a patient must be supported by signs and symptoms. every nursing diagnosis has a list of defining characteristics (symptoms). this is no different from medical diagnoses. before a doctor assigns any medical diagnosis to a patient he/she does a review of systems and physical exam and bases the diagnosis on symptoms he/she has found. schizophrenia, the medical diagnosis, has a list of signs and symptoms (see above). impaired skin integrity, the nursing diagnosis, also has a list of symptoms, only nanda calls them defining characteristics. to assign that diagnosis to a patient you will have done an assessment and the patient will need to have at least one or more of the defining characteristics. it is also a good idea to read the definition of the diagnosis. the reason is because the definition gives you a more complete description of the patient problem. the 3, 4 word diagnoses you will be using are actually shorthand labels.

so, how do you find a suitable diagnosis? with time and experience you learn. the front section of nursing diagnosis handbook: a guide to planning care by betty j. ackley and gail b. ladwig cross references medical diagnoses and conditions with lists of likely nursing diagnoses to use. but, these are only suggestions. there have been times when i have taken my copy of the taxonomy and just flipped through from page 1 onward looking at defining characteristics and definitions trying to find the diagnosis to fit with the symptoms my patient had. and, i always find it in the last place i look.

so, what you have to do now, is make a list of this patient's symptoms and then determine what you feel are appropriate nursing diagnoses. just from the information posted i see at least two actual (real, based on facts in evidence) nursing problems that i would give nursing diagnoses to.

prioritizing has to do with the order of importance. most instructors prefer that students prioritize their nursing diagnosis according to maslow's hierarchy of needs. actual nursing problems are always listed and prioritized before potential (anticipated, or "risk for") problems. this is the hierarchy:

1. physiological needs (in the following order)
   • the need for oxygen and to breathe [the brain gets top priority for oxygen, then the oxgenation of the heart followed by oxygenation of the lung tissue itself, breathing problems come next, then heart and circulation problems--this is based upon how fast these organs die or fail based upon the lack of oxygen and their function.]
     
     
   • the need for food and water
     
     
   • the need to eliminate and dispose of bodily wastes
     
     
   • the need to control body temperature
     
     
   • the need to move
     
     
   • the need for rest
     
     
   • the need for comfort

• safety from physiological threat
  
  
• safety from psychological threat
  
  
• protection
  
  
• continuity
  
  
• stability
  
  
• lack of danger

• affiliation
  
  
• affection
  
  
• intimacy
  
  
• support
  
  
• reassurance

• sense of self-worth
  
  
• self-respect
  
  
• independence
  
  
• dignity
  
  
• privacy
  
  
• self-reliance

• recognition and realization of potential
  
  
• growth
  
  
• health
  
  
• autonomy

if you follow the nursing process you should have no trouble outlining your rationale for your choice of the nursing diagnoses you make.

hope that helps you get started. i didn't move on to any further steps because you didn't ask about them. if you have any other questions, just ask.

What are the two best nursing diagnoses that should be used in this case?

This is your paper, your grade. I gave you a lot of information that you would otherwise have had to look up yourself as well as some hints. It's your turn to contribute here. What do you think the two best nursing diagnoses are and why?

nursing diagnoses that i have come up with are:

- non-compliance

- social isolation

- disturbed sleep pattern

- ineffective coping

- ineffective health maintenance

- spiritual distress

does anybody have suggestions as to which of these i can use as "two priority problems???"

btw, thanks heaps daytonite!!!

i gave you the maslow hierarchy of needs. you prioritize by that.

1. disturbed sleep pattern (physiological need)
   
2. ineffective health maintenance (safety and security need)
   
3. social isolation (love and belonging need)
   
4. ineffective coping (self-esteem need)
   
5. noncompliance (self-esteem need)
   
6. spiritual distress (self-actualization need)

however, i don't think you have the evidence (symptoms) to support the use of some of these unless you have added information to this case study that you are not sharing. i would like to see your 3-part nursing diagnostic statements if you are required to write them for this assignment.

look very carefully at the definition of noncompliance and compare it with the definition of ineffective health maintenance. the nanda definition of noncompliance is not the same as what the medical community (doctors) call noncompliance. don't be tricked into using this diagnosis just because the word was used in the scenario you were given. read the definitions of these diagnoses so you know what you are labeling some poor schmuk with. make sure you know the difference between noncompliance and ineffective health maintenance because it is subtle and essentially the same but involving the patient's attitude toward their treatment.

how are you addressing the patient's desire for information about the impact of marijuana use in schizophrenics (knowledge deficit [marijuana use]?) and his own substance abuse of marijuana? (ineffective denial?) are you considering any of the symptoms of schizophrenia? did the diagnosis of disturbed thought patterns r/t inaccurate interpretation of environment enter your thoughts? that is a very typical response of schizophrenics--at times they kind of live in their own little fantasy world oblivious to what is going on with others. they hallucinate and hear voices--very sad.